Intended for healthcare professionals

Rapid response to:


International regulation of alcohol

BMJ 2008; 337 doi: (Published 07 November 2008) Cite this as: BMJ 2008;337:a2364

Rapid Response:

Broadening the Frame for Debate on Public Health Policies Regarding Alcohol

Broadening the Frame for Debate on Public Health Policies Regarding

Not only is the idea of a Framework Convention for Alcohol Control
(FCAC) not addressed in the response by Ellison & Xhang (e-BMJ, 13
Nov. 2008) to our editorial (1), but the whole issue of health inequity
and socioeconomic disparities is sidelined. The main point of our
editorial was that public health controls are needed to balance the move
to free markets that, by its very nature, undercuts existing alcohol
control policies put in place by nation states – policies that we know
from the research evidence actually work to reduce public health harms
attributable to alcohol (2). Worldwide, the people most likely to suffer
from the absence of such controls are the poor (3) and people in countries
undergoing rapid development, such as China and India (4). These emerging
markets are precisely those most aggressively targeted with marketing by
alcohol producers and distributors.

In this context, it is inappropriate to focus on the ischemic heart
benefits of moderate drinking as this response does. First, the majority
of people around the world do not drink moderately and regularly, in such
a way as to experience these benefits (4, 5). Instead, poorer populations
around the world will be much more affected by such factors as alcohol
poisoning, injuries, negative social consequences, alcohol dependence and
related stigma, and health problems such as tuberculosis (6), conditions
which are exacerbated by poor nutrition and lack of access to health care.
By focusing on risk of ischemic heart disease, the commentary reflects a
somewhat narrow class-based position that is common in Western medicine,
where practitioners are right to be concerned about whether patients
exercise, drink moderately and eat fruits and vegetables. But even in
high-income countries, the harm outweighs the benefits of alcohol
consumption (4), often even for people with moderate drinking patterns on
an averaged basis (7). An equitable public health perspective should voice
the needs of populations who may not have access to a lifespan as long as
in Japan, and an affluent lifestyle and excess of red meat in the diet,
thereby making ischemic heart disease the overwheming health concern.
Moreover, it is unlikely that a Framework Convention on Alcohol Control
would deprive patients of the benefits of moderate drinking in affluent
countries. It would merely position other countries around the globe to
allow control policies to limit the harm caused by alcohol.

Laura Schmidt, Associate Professor, Philip R Lee Institute for Health
Policy Studies, University of California, San Francisco

Jürgen Rehm, Professor, Dalla Lana School of Public Health,
University of Toronto

Robin Room, Professor, School of Populatioon Health, University of

Pia Mäkelä, Senior Researcher, STAKES, Helsinki.


1. Room R, Schmidt L, Rehm J, Mäkelä P. International regulation of
alcohol. BMJ 2008;337:a2364.

2. Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et
al. Alcohol: no ordinary commodity – research and public policy. Oxford:
Oxford University Press, 2003.

3. Schmidt LA, Mäkelä P, Rehm J, Room R. Alcohol and social determinants
of health. In: Blas E, Sivasankara K, editors. Priority public health
conditions: from learning to action on social determinants of health.
Geneva, Switzerland: WHO, in press.

4. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, Sempos CT, Frick
U, Jernigan D. Alcohol use. In: Ezzati M, Lopez AD, Rodgers A &
Murray CJL, eds. Comparative Quantification of Health Risks. Global and
Regional Burden of Disease Attributable to Selected Major Risk Factors.
Vol. 1. Geneva: WHO, 2004:959-1108.

5. Bagnardi V, Zatonski W, Scotti L, La Vecchia C, Corrao G. Does
drinking pattern modify the effect of alcohol on the risk of coronary
heart disease? Evidence from a meta-analysis. J Epidemiol Community Health

6. Szabo G. Alcohol and susceptibility to tuberculosis. Alcohol Health
& Research World 1997;21(1):39-41.

7. Rehm J, Patra J, & Taylor B. Harms, benefits and net effects
on mortality of moderate drinking of alcohol among adults in Canada in
2002. Annals of Epidemiology 2007;17:S81-S86.

Competing interests:
None declared

Competing interests: No competing interests

17 November 2008
Laura Schmidt
Associate Professor
Jürgen Rehm, Robin Room, and Pia Mäkelä
Philip R Lee Institute for Health Policy Studies, University of California, San Francisco 94118, CA